Complex F
A nurse cares for a client recovering from prosthetic valve replacement surgery. The client asks, "Why willI need to take anticoagulants for the rest of my life?" How should the nurse respond?
"Blood clots form more easily in artificial replacement valves.
The male client is diagnosed with coronary artery disease and is prescribed sublingual nitroglycerin. Which statement indicates the client needs more teaching?
"If my chest pain is not gone with tablet, I will drive to the ER."
The nursing instructor asks the student nurse, "What is the mechanism of action for Rivaroxaban (Xarelto)?
"It inhibits factor 10 in your clotting system.
A client is on mechanical ventilation and the client's spouse wonders why ranitidine (Zantac) is needed since the client "only has lung problems" What response by the nurse is best?
"It will prevent ulcers from the stress of mechanical ventilation
A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory abilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed?
1630 (4:30 PM)
A61 year old male is admitted to your unit with the diagnosis of upper GI bleeding. He has a history of alcohol abuse and prior Gl bleeding. His abdomen is distended and his liver is enlarged. he has no complaints of pain, but is having active hematemesis. What condition do you suspect?
Cesophageal variceal bleeding
Which statement is true regarding status asthmaticus?
Corticosteroids, although useful in the treatment of status asthmaticus, usually require 6 to 8 hours to take effect.
The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.)
Decreased muscle strength Less lung elasticity Chest wall stiffness
A nurse assesses a client with mitral valve stenosis, What clinical manifestation should alert the nurse to the possibility that the client's stenosis has progressed?
Dyspnea on exertion
The physician states that you need to decrease the Preload in your heart failure patient. You know that this means you may be doing the following: (SELECT 2)
Encourage a low Na diet Give Furosemide (Lasix) IV
All of the following are immediate interventions for a patient experiencing a Myocardial Infarction, EXCEPT:
Enteric coated aspirin 81 mg X 1
A nurse assesses a client with pericarditis. Which assessment finding should the nurse expect to find?
Friction rub at the left lower sternal border
A patient has a small bowel obstruction, which is being treated medically. the NG tube output has been 2400 ml over the last 24 hours. Which electrolyte disturbance can occur in a patient with excessive NG tube output?
Hypokalemia
Identify what leads have an ST elevation
II, IIl and aVF
Which of the following leads are used in the diagnosis of an inferior MI?
II, IIl and aVF
A 76 year old woman is brought to your unit with a diagnosis of heart fallure. She is begun on a dobutamine drip. What is the expected result of this type of therapy?
Increase in stroke volume
A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 60 seconds. What action by the nurse takes priority?
Interrupt the procedure to give onygen
An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority?
Listen to the client's lung sounds
The nurse caring for a client who is taken off a ventilator and placed on continuous positive airway pressure (CPAP), What intervention is most appropriate for this client?
Making sure the client is breathing spontaneously
A nurse assesses a client who is recovering from a heart transplant. Which assessment findings should alert the nurse to the possibility of heart transplant rejection? (Select 3)
New-onset bradycardia Shortness of breath Abdominal bloating
The nurse is caring for a client with a chest tube after a coronary artery bypass graft. The drainage slows significantly. What action by the nurse is most important?
Notify the provider immediately.
The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.)
Adherence to proper hand hygiene Providing oral care per protocol Administering anti-ulcer medication
The nurse assesses a client admitted for chest trauma who reports dyspnea. The nurse finds tracheal deviation and a pulse oximetry reading of 86%. What is the nurse's priority intervention?
Administer oxygen and prepare for chest tube insertion.
While assessing a client on a cardiac unit, a nurse identifies the presence of an Sa gallop. Which action should the nurse take next?
CAssess for symptoms of left-sided heart failure.
An older adult is on cardiac monitoring after a myocardial infarction. The client shows frequent dysrhythmias. What action by the nurse is most appropriate?
Assess for any hemodynamic effects of the rhythm
A client has intra-arterial blood pressure monitoring after a myocardial infarction. The nurse notes the client's heart rate has increased from 88 to 120 beats/min, and the blood pressure dropped from 120/82 to 90/60 mm Hg. What action by the nurse is most appropriate?
Assess the client for bleeding
A nurse is caring for a client who is intubated and has an intra-aortic balloon pump. The client is restless and agitated. What action should the nurse perform first ?
Assess the patient's oxygenation
A nurse is caring for a postoperative 70-kg client who had major blood loss during surgery. Which findings by the nurse should prompt immediate action to prevent acute kidney injury? (Select all that apply.) Select all that apply.
Blood pressure of 90/60 mm Hg Large amount sediment in the urine Urine output of 100 mL in 4 hours
A client undergoing hemodynamic monitoring after a myocardial infarction has a CVP pressure of 1mm Hg. What action by the nurse is most appropriate?
Prepare to administer a fluid bolus.
A client is brought to the emergency department after sustaining injuries in a severe car crash. The client's chest wall does not appear to be moving normally with respirations, axygen saturation is 82%, and the client is cyanotic. What action by the nurse is the priority?
Prepare to asist with intubation
A nurse is assessing a client with left-sided heart failure. For which clinical manifestations should the nurse assess? (Select 3)
Pulmonary crackles Confusion, restlessness Cough that worsens at night
A 34 year old woman is admitted to your unit one week after a cesarean She has not prior cardiopulmonary history. Her vital signs are: BP- 90/55, HR 140, RR- 62 on 3L nasal cannula. Based on the information, which condition is likely occurring in this patient? 36, Her ABG's are Ph- 7.46, PCO2-33, Pa02-
Pulmonary emboli
A nurse is caring for a client with acute pericarditis who reports substernal precordial pain that radiates to the left side of the neck. Which nonpharmacologic comfort measure should the nurse implement?
Sit the client up with a pillow to lean forward on.
A client with acute kidney injury has a blood pressure of 76/55 mm Hg. The health care provider ordered 1000 mL fnormal saline to infused over 1 hour to maintain perfusion. The client is starting to develop shortness of breath. What is the nurse's priority action?
Slow down the normal saline infusion.
A nurse assesses a client with ulcerative colitis. Which complications are paired correctly with tlaeir physiologic processes? (Select all that apply.) Select all that apply.
Toxic megacolon Abscess formation Lower GI bleeding
While triaging clients in a crowded emergency department, a nurse assesses a client who presents with symptoms of tuberculosis. Which action should the nurse take first?
Transfer the client to a negative-pressure room.
When should heart failure patient seek immediate Medical attention?
Weight gain of 3 Ibs overnight
What is the most likely explanation for the Hg and Hct values?
the values are decreased because of loss of erythropoietin
A client received tissue plasminogen activator (t-PA) after a myocardial infarction and now is on an intravenous infusion of heparin. The client's spouse asks why the client needs this medication. What response by the nurse is best? a. "The t-PA didn't dissolve the entire coronary clot." b. "The heparin keeps that artery from getting blocked again." c. "Heparin keeps the blood as thin as possible for a longer time." d. "The heparin prevents a stroke from occurring as the t-PA wears off."
b. "The heparin keeps that artery from getting blocked again."
The nurse is assessing a client who has undergone a percutaneous transluminal coronary angioplasty (PTCA) and is ordered to receive an IV infusion of abciximab (ReoPro). Which clinical manifestation does the nurse monitor for in this client?
bleeding
Which of the following is a common sign of cardiac tamponade?
decreased systolic BP more than 10 mmHg upon inspiration (pulsus paradoxus)
A nurse assesses a client with peritonitis. Which clinical manifestations should the nurse expect to find? (Select Three)
decreased urine output Odistended abdomen inability to pass flatus
A patient being mechanically ventilated develops hypotension after the respiratory therapist implements the most recent physician orders. The nurse suspects which ventilator setting might be the cause?
increase in PEEP from 5cm to 15 cm
Which of the following is a symptom of Beck's triad?
increased jugular distention
The priorities for the care of a client with acute glomerulonephritis are:
monitoring daily weight recording BP at least q 4 hr maintaining strict 160
A 24 year old patient underwent exploratory laparotomy and a partial colectomy after being stabbed in the right lower quadrant. On post op day 6, the patient's wound starts to drain brown fluid. His temp is 101.5 Fand WBC is 18,000. His abdomen is soft, he has hypoactive bowel sounds and denies nausea or vomiting. You suspect the patient has developed?
sepsis at the incision site